Reducing Hospital Admissions for Patients with Heart Failure by Implementing the Chronic Care Management Framework: A Cost, Quality and Satisfaction Improvement Project.

Abstract

To reduce the rate of hospital admissions, and increase the perception of coordinated care for patients with heart failure and associated co-morbidities through improvement of interdisciplinary communication. Heart failure patients with associated multi-morbidities and multiple provider visits are often left to navigate the health system independently. Limited provider to provider communication contributes to care fragmentation, unnecessary utilization and decreased satisfaction. A nurse led complex care management improvement project imbedded care plans and formal and informal collaborative care conferences to improve interprofessional communication across the care continuum. Hospital admissions decreased by 62% and length of stay decreased by 73% (n = 47, p < .001). Using paired t-test, satisfaction questions improved post intervention, and one was statistically significant (p < 0.05). Improved communication strategies decreased hospital admissions and length of stay in one large Pacific Northwest health system. Days subject to readmission penalties decreased by 98% with a variance in pre-post charges of $615,000. Nurses and nurse leaders play a significant role in achieving the Triple Aim and can be instrumental in developing small multidisciplinary teams targeting improved coordination across settings and sectors.